Provider Demographics
NPI:1033278361
Name:BROADNAX, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:404-688-9305
Mailing Address - Fax:404-688-0621
Practice Address - Street 1:1289 BROAD ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1187
Practice Address - Country:US
Practice Address - Phone:706-724-5557
Practice Address - Fax:706-724-5293
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA586045874OtherPEACHSTATE HEALTH PLAN
GA586045874OtherCIGNA HEALTHCARE
GA586045874OtherBCBS OF GEORGIA
GA586045874OtherAMERIGROUP COMMUNITY CARE
586045874OtherAETNA HEALTHCARE
586045874OtherHUMANA
GA586045874OtherUNITED HEALTHCARE
SCG16213OtherSOUTH CAROLINA MEDICAID